Refusing treatment for diabetes

An update from a regular series written by Mr Robert Wheeler, director, department of clinical law, where he considers various aspects of clinical law that our nursing staff, medical staff and other professions rely on when caring for patients.

MC was fifty-three, detained for 20 years in a high security hospital under the Mental Health Act 1983. He suffered from a severe personality disorder, and was a ‘restricted patient,’ in the sense that he could not be discharged from the hospital without the consent of the Secretary of State for Justice. Patients in the ‘restricted’ category are considered to pose a grave danger to themselves or others. Suffering for many years from insulin dependent diabetes, MC had complied poorly with treatment; the court was told that in hospital custody he had ‘deliberately mismanaged’ his diabetes, refusing glucose monitoring and ‘most of his daily insulin.’

The NHS trust looking after MC sought a declaration by the court that it would be lawful not to impose diabetic treatment on MC without his consent…even if the resultant suboptimal treatment led to continual physical deterioration and a risk of his death. This was consistent with MC’s position; that treatment should not be forced upon him.

MC was now suffering consequences of poor diabetic control, with severe hypertension (for which he refused medication) and peripheral vascular disease. He had undergone a below-knee amputation in the year preceding this hearing, and had diabetic retinopathy, neuropathy, and nephropathy. MC refused to accept medical treatment for any aspect of his many diabetes-related pathologies, and it was accepted by all involved that he had mental capacity to make this refusal. Nevertheless, the court was told that MC had recently developed an infection in his remaining (left) foot, manifesting as cellulitis. A vascular surgical discharge summary included a report of deliberate interference by MC; ‘…with the healing process of the foot, by placing the foot in faeces.’ The court reflected; ‘His disinclination to cooperate with treatment in relation to the diabetic foot…understanding the consequences of not complying…and his explicit statement that he does not want to die… underscores the complexity of MC’s situation from a psychiatric perspective.’

MC was supportive of the Trust’s application, that it would be lawful not to impose treatment upon him. A witness’ comment reveals the dilemma facing the clinicians; ‘I worry about a situation where a nurse gives him insulin in the evening in those circumstances and he is hypoglycaemic overnight and dies. The coroner will ask the nurse if they gave him insulin, and did you check his blood sugar level before you gave it?’ The clinicians’ inability properly to treat MC’s diabetes was daunting.

The court accepted that s63 of the Mental Health Act 1983 would in principle make lawful enforced treatment for MC’s diabetes under that Act, since his refusal of the treatment of his diabetes could be considered a manifestation of his personality disorder. But the clinicians involved realised that he would have to be subjected to restraint, and that forceful administration risked exacerbating his existing pathology, such as his hypertension, with potentially adverse outcomes. For this reason, the court made the declaration sought by the Trust: That it was lawful not to use force to provide MC with care for his diabetes…and therefore clinicians were not to be able to provide usual treatment…even if his early death might be a consequence.

Nottinghamshire Healthcare NHS FT v MC & Ors [2025] EWHC 920 (Fam)

Mr Robert Wheeler
Department of clinical law
October 2025